Healthcare Provider Details

I. General information

NPI: 1649554742
Provider Name (Legal Business Name): YAHYA A.M. ELZARUG B.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2011
Last Update Date: 10/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KNEELAND ST
BOSTON MA
02111-1527
US

IV. Provider business mailing address

1 KNEELAND ST
BOSTON MA
02111-1527
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-6930
  • Fax: 617-636-6809
Mailing address:
  • Phone: 617-636-6930
  • Fax: 617-636-6809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDL11438
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: